South Africa’s Psychiatric training capacity in 2008 and in 2018. Has training capacity improved?

Background There is a deficit of psychiatrists in South Africa, and to our knowledge, there is no situational analysis of training posts for psychiatrists in the country. Aim To compare the number of specialists and subspecialists in training and training posts available in 2008 and 2018. Setting South African medical schools with departments of psychiatry. Methods A situational analysis involving data collection through a survey completed by eight heads of academic psychiatric departments followed by a comparative analysis of the two aforementioned years. Results Data shows an 11% increase in funded and unfunded posts combined and a 9.3% increase in funded posts. The occupancy of funded posts decreased (92% in 2008 to 82% in 2018). When considering both funded and unfunded posts, only three more psychiatrists were being trained in 2018. Supernumeraries appointed in unfunded posts can be expected to return to their countries of origin. As such, a decrease in filled funded posts likely reflects a decrease in training psychiatrists destined to work in South Africa. While child and adolescent psychiatry was the only sub-speciality with accredited training posts in 2008, all sub-specialities included on the questionnaire had accredited training posts in 2018, and the number of accredited training posts in child and adolescent psychiatry doubled. That said, many of the posts were unfunded and vacant. Conclusion While there was an increase in posts from 2008 to 2018, many posts remained unfilled. As such, not only are additional funded training posts required but also strategies to increase post-occupancy and successful completion of training. Contribution This study is the first situational analysis of specialist and subspecialist training posts in Psychiatry in South Africa, at two time points over a 10 year period, that draws on academic heads of departments of psychiatry as respondents. The study highlights the nominal increase in funded training posts over this period, especially subspecialist training posts. The majority of Health Professions Council of South Africa (HPCSA) accredited subspecialities in Psychiatry have no funded training posts which is particularly concerning.


Introduction
The South African Stress and Health (SASH) study, the only nationally representative study of its kind in South Africa to date, documented a 30.3% lifetime prevalence of common mental disorders in the country. 1,2 There are no similar representative studies in South Africa other than SASH; however, international studies such as Patel et al. have shown a trend of an increasing burden of mental illness over time; in the aforementioned study there was a 41% increase in this burden over one decade. 3 The recent COVID-19 pandemic seems to have also contributed to an increase in mental health care needs. 4 A recent National Department of Health commissioned study recommended that in the context of decreasing the need for specialists in healthcare through a task shifting model, 3.00 psychiatrists per 100 000 population would be required to meet population needs. 5 This is concerning as even in the context of a well-developed task-shifting model, the current ratio of

South Africa's Psychiatric training capacity in 2008 and in 2018. Has training capacity improved?
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http://www.sajpsychiatry.org Open Access 1.52-1.53 psychiatrists per 100 000 population in South Africa falls far short of population requirements. 6,7 In South Africa, an undergraduate medical degree (generally requiring 6 years training) and completion of a 2-year internship and 1-year community service is a minimum requirement before one can apply for a specialist training post in psychiatry (an additional 4 years training). 8 Individuals who have successfully completed their specialist psychiatry training are eligible to apply for sub-specialist training posts in Addiction Psychiatry, Old Age or Geriatric Psychiatry, Child and Adolescent Psychiatry, Neuropsychiatry, Forensic Psychiatry or Consultation-Liaison Psychiatry (an additional 2 years training). 9 While the main examination body for specialist and subspecialist psychiatric training is the Colleges of Medicine of South Africa (CMSA) through the College of Psychiatrists, the majority of training is conducted by the nine universities registered for specialist and subspecialist training across the country. These institutions also confer the MMed degree in The provincial departments of health in the nine provinces that make up South Africa are generally the main employers of registrars who are specialising or sub-specialising through funded training posts (a training post entails full-time employment with overtime requirements; trainees in funded posts are fully renumerated for their hours of employment as contracted). However, there are also training posts with registered training numbers that are not funded by the provincial department of health (unfunded), and trainees are required to source funding independently for these posts (e.g. foreign nationals from other African states who may be funded by their own government or hospital). Substantial waiting lists for funded training posts have previously been described; 10 however, there is no recent evidence that this trend has continued.
Considering the historical and present deficits in the number of psychiatrists in the country, 6 the authors undertook a comparison of the number and the occupancy of specialist training posts in 2008 and 2018 and compared the ratio of trainees to trainers at the respective training institutions.

Research methods and design
The heads of department (HODs) of the nine academic psychiatry departments in South Africa were asked to provide data by means of a questionnaire. Of the nine departments, eight responded including UL, UP, UFS, WITS, SU, UKZN, WSU and UCT.

Statistical analysis
All data were summarised as absolute counts and percentages using Excel.     In the final section of the survey, HODs were asked if they believed the number of training posts at their respective institutions was adequate to meet population needs. All commented that there were shortages, particularly highlighting the lack of funded sub-specialist training posts.

Discussion
While long waiting lists for specialist psychiatric training posts were previously mentioned, 10     The pass rates over this period are concerning considering: (1) the need to increase the psychiatrist-to-population ratio in the context of a growing population (1.3% per year) 11 and (2) qualified psychiatrists leaving practice in South Africa either because of retirement (n: 33; 4.5%, at retirement age) 1 or emigration. 12 Many of the unfunded posts are occupied by foreign trainees who are likely to leave South Africa after their training is completed and therefore will have no sustained impact on the psychiatrist-to-population ratio in the country.
If it is assumed that the South African population in 2019 was 58 558 270 13 and three psychiatrists are required per 100 000 population, this would equate to a total of 1756.75 psychiatrists. In 2019, the active population of psychiatrists is said to have been 793, 6 14 it can be expected that the mental healthcare needs of this population will also increase. The majority of available subspecialist training posts were vacant in 2018. To date, there are very few HPCSA-approved training post numbers for Addiction Psychiatry, yet South Africa has very high rates of substance abuse with marked psychosocial impact, 15,16,17,18 while the treatment of substance use disorders has been shown to be cost effective. 19 There are a variety of factors that may be contributing to general medical practitioners and specialist psychiatrists not pursuing specialist and subspecialist training. Some that have been mentioned in the past include HPCSA's decisions on which academic units should be allocated specialist and subspecialist training posts and which subspecialities get accredited, as well as limiting the total number of subspecialist training posts per institution to two per subspecialist (for each subspecialist employed by an academic department the possible number of subspecialist training posts for that particular subspeciality that the academic department can apply for is capped at two) and the National Department of Health and the Department of Higher Education and Training being the only bodies that can authorise training of specialists and sub-specialists with training only possible through the public healthcare sector as a 4-year (specialist) and 2-year full-time or 4-year part-time course (sub-specialist). 20 As such, general practitioners and psychiatrists working in the private sector would have to leave their private practices and make economic sacrifices to pursue specialist and subspecialist training, respectively. A possible solution that has been suggested is public-private partnerships, with trainees working in both the private and public sectors and receiving subspeciality exposure in both settings but also jointly drawing on private and public entities for potential funding for such training. Alternatively, making more widely available the 4-year part-time subspecialist training option, allowing trainees to continue their private practice. Another obstacle to specialising or sub-specialising may be the need to relocate to cities with universities that offer specialist and sub-specialist training. Distanced learning may help to alleviate this problem with the possibility of an adapted curriculum where decentralised facilities with remote psychiatrist supervisors can be accredited, allowing trainees to work in their home practice environment for extended periods and spend shorter, concentrated periods at an academic institution. Not having to relocate has the additional benefit of possibly distributing specialists and sub-specialists across the country in a more equitable manner as specialists and sub-specialists are currently concentrated in geographic pockets of South Africa, 6 likely close to where they originally specialised. Of note, the majority of registrars training in psychiatry indicated in a survey conducted in 2019 that they intended to remain in the province they were located in during their training once their training was completed. 18 Considering the aforementioned, merely adding training posts to university hospitals that do not have vacant posts would not solve the problem of inequitable distribution of psychiatrists across the country. The reasons why certain universities have vacant posts and others not are not clear but may include (1) location universities located in cities with qualities that trainees may find desirable for themselves or to raise a family in. Thus, being located near large cities where many general practitioners or specialist psychiatrists already reside and not needing to relocate to pursue training. Related to this may be familiarity with a training institution (e.g. choosing the institution where undergraduate training was undertaken).
(2) Qualities of the training institution itself -a survey among training psychiatrists in 2019 indicated significant variability in trainees' perception of the quality of their training and resources at their training facilities. 18 Differences across institutions in the numbers of filled and vacant posts in 2008 and 2018 are difficult to explain considering that the data presented here reflect two time points rather than longitudinal year-on-year estimates. Drawing comparisons and providing reasons for the discrepancies and the potential impact would, therefore, be purely speculative. Filling of registrar posts is a dynamic annual process with different institutions in the country filling registrar posts at different times in the calendar year. That said, the increase in training post numbers nationally (which in the absence of an increase in provincially funded registrar posts across the country, over time) represents a strategic effort on the part of university departments of psychiatry to increase capacity on the service training platform in light of the increase in mental health service demands.
Shortcomings of the study include that not all nine universities that provide specialist and sub-specialist psychiatry training in South Africa responded to the survey of this study and of the universities that did respond some did not have comparable data for both 2008 and 2018. As such, the actual increase in the number of specialist and sub-specialist training posts from 2008 to 2018 was difficult to determine. In addition, SMU prior to 2015 was known as MEDUNSA campus and was part of the Limpopo University. In 2015, MEDUNSA campus split from the Limpopo University and became SMU. Thus, any posts added in 2018 through the establishment of SMU in 2015 must be viewed with this background in mind. That said, the eight universities that did respond to the questionnaire represent the largest universities in the country that offer registrar training in Psychiatry. The data represent a cross-sectional analysis covering two calendar years approximately 10 years apart and may not be representative of sustained trends between 2008 and 2018, and lastly, HODs may have also completed the questionnaire without consulting their human resource department or personnel records, resulting in inaccurate data.

Conclusion
While long waiting lists for specialist psychiatry training posts were previously described, this situation analysis shows multiple vacant specialist posts at training institutions in the country. Despite an increase in the number of specialist psychiatry training posts from 2008 to 2018, South Africa is unlikely to reach the recommended number of three psychiatrists per 100 000 population with the current funded post allocations in the next two decades if retirement, migration and population growth are considered, even if all vacant posts were filled, and all trainees have successfully completed their training within the stipulated time frame. Not only are additional funded training posts required but also strategies to increase post occupancy, retention and successful (and timeous) completion of training.